| National Provider Identifier [NPI]: | 1629233770 |
| Last Name Of The Provider | BLACKWELL |
| First Name Of The Provider | KISSI |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3301 STALCUP RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WORTH |
| Zip Code Of The Provider | 761191726 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 33 |
| Number Of Services | 567 |
| Number Of Medicare Beneficiaries | 212 |
| Total Submitted Charge Amount | 95541.07 |
| Total Medicare Allowed Amount | 40254.16 |
| Total Medicare Payment Amount | 29343.78 |
| Total Medicare Standardized Payment Amount | 30380.33 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 46 |
| Number Of Medicare Beneficiaries With Drug Services | 39 |
| Total Drug Submitted ChargeAmount | 4019.9 |
| Total Drug Medicare AllowedAmount | 1811.84 |
| Total Drug Medicare PaymentAmount | 1774.98 |
| Total Drug Medicare Standardized Payment Amount | 1774.98 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 28 |
| Number Of Medical Services | 521 |
| Number Of Medicare Beneficiaries With Medical Services | 212 |
| Total Medical Submitted Charge Amount | 91521.17 |
| Total Medical Medicare Allowed Amount | 38442.32 |
| Total Medical Medicare Payment Amount | 27568.8 |
| Total Medical Medicare Standardized Payment Amount | 28605.35 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 78 |
| Number Of Beneficiaries Age 65 to 74 | 79 |
| Number Of Beneficiaries Age 75 to 84 | 42 |
| Number Of Beneficiaries Age Greater 84 | 13 |
| Number Of Female Beneficiaries | 148 |
| Number Of Male Beneficiaries | 64 |
| Number Of Non Hispanic White Beneficiaries | 106 |
| Number Of Black or African American Beneficiaries | 79 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 122 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 90 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 22 |
| Percent Of With Chronic Kidney Disease | 26 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 21 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 45 |
| Percent Of With Hyperlipidemia | 64 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 34 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 52 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.4105 |